Petition to Appeal Charges Student Information Name (Last, First):
Preferred Name:
Student 10-Digit ID:
Date of Charge(s) (MM/DD/YY):
Amount Disputed:
Instructions Please provide your reason supporting your appeal of the charge(s): ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________
Certification ☐ I affirm that the information provided on this form is true and accurate.
_________________________________________________ Student’s Legal Signature
_____________________________________ Date (MM/DD/YY)
Submittal The completed form must be sent to the Insurance & Billing Department at Student Health within 30 days of the date of the charge(s). Once completed, please return the form: In person: 1031 W. 34th Street, Suite LL-101, Los Angeles, California 90089 Fax: 213‐228‐5046 Email: studenthealth@usc.edu Notification You will be notified by USC Student Health regarding the decision on your petition. All decisions will be communicated through your USC email account on record within fifteen (15) business days. For Administrative use only: ☐ Approved
☐ Not Approved
Reason:
___________________________________ Approved By (Last, First)
__________________________________ Title
___________________________ Date (MM/DD/YY)
1031 W. 34th Street, Los Angeles, California 90089-3261 • (213) 740-9355 INS_BLLDSP_011924_V1